Nurse Utilization Review Specialist

1 week ago


Edgewater, New Jersey, United States VNS Health Full time
About the Role

VNS Health is seeking a skilled Nurse Utilization Review Specialist to join our team. As a key member of our quality improvement team, you will play a critical role in ensuring the highest level of patient care and satisfaction.

Key Responsibilities
  • Conduct thorough clinical assessments, including medication reconciliations, post-discharge transitions of care, and emergency department assessments.
  • Collaborate with healthcare teams to ensure compliance with regulatory requirements, industry benchmarks, and strategic quality objectives.
  • Lead and participate in quality improvement initiatives, including performance measurement, documentation, and process improvement.
  • Develop and implement corrective action plans to address non-adherence and clinical diagnosis for HEDIS/QARR exclusion.
  • Conduct audits of patient care records, provide counseling and guidance to primary care providers on VNS Health Medical Record Documentation Standards, and develop tools for concurrent and retrospective patient care review.
  • Perform utilization and quality assessment reviews to maintain compliance with Federal and State regulatory requirements, identify areas for improvement, and develop action plans.
  • Participate in site visits, investigations, and root cause analysis to inform quality improvement initiatives.
  • Develop training materials, protocols, and standards for patient populations within a collaborative framework.
  • Conduct follow-ups and reassessments to evaluate the effectiveness of corrective actions.
Requirements
  • License and current registration to practice as a Registered Professional Nurse in New York State required.
  • Minimum of three years quality improvement experience in a health plan or healthcare setting required.
  • Minimum of one year experience in quality management, practice improvement, and compliance preferred.
  • Demonstrated leadership experience preferred.
  • Excellent oral, written, and interpersonal communication skills, including group facilitation skills required.
  • Knowledge of basic Performance Improvement tools and methodologies preferred.


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